Emergency Endovascular Stroke Service Recommended

The establishment of a national emergency service providing next generation stroke therapy for selected stroke patients in two hospital sites in Ireland has been recommended by HIQA as part of a health technology assessment (HTA).

Dr. Mάirίn Ryan
Dr. Mάirίn Ryan

This treatment would be in addition to the standard medical care for stroke.

HIQA said that in comprehensive stroke centres, the HTA found that endovascular treatment with mechanical thrombectomy using tiny devices to physically retrieve clots from the brain was safe and effective when provided in addition to the current standard medical care. This procedure needs to be carried out within six to 12 hours of onset of symptoms of an acute ischaemic stroke.

Dr. Máirín Ryan, HIQA’s Deputy Chief Executive and Director of Health Technology Assessment, said: “Based on doing 268 procedures a year in carefully selected patients, an additional 57 patients are predicted to regain functional independence at 90 days after a stroke. This represents a substantial improvement, with almost 60% regaining functional independence compared with less than 40% without the procedure.”

“Mechanical thrombectomy in conjunction with the current standard medical care is significantly more likely to result in patients who have had a stroke regaining functional independence. The evidence is conditional on the procedure being used with non-invasive arterial imaging, in selected patients, and when using newer stent-retriever devices to remove blood clots from the brain.

“Expanding access to mechanical thrombectomy in Ireland has implications for the organisation of acute stroke service to ensure efficient presentation, identification and treatment of patients in the first hours after the onset of the symptoms of a stroke.”

The five-year budget impact of a national emergency mechanical thrombectomy service compared to no service is estimated in HIQA’s HTA at €7.2 million

The findings have been presented as advice to Minister for Health and the HSE.

HIQA’s HTA also found that an organised national service would need detailed planning to ensure it adheres to quality standards. “An equitable, high quality and cost-effective national service can only be provided if the procedure is offered in a small number of centres that are adequately resourced and sited to maximise patient access, workforce expertise and geographical coverage.”

Dr. Ryan said: “Ensuring equitable access to and benefit from mechanical thrombectomy will require the existing regional variability in timely access to acute stroke care and stroke services to be addressed. There are significant organisational and resource implications also for the National Ambulance Service to ensure the timely transfer of patients to the national treatment centres and to repatriate them to their local acute stroke service post-procedure without compromising provision of ambulance services for other patients.”

Each year in Ireland an estimated 10,000 people have a stroke-related event and an estimated 2,000 people die as a result of stroke.

In Ireland, approximately 4,300 people are admitted to hospital following an acute ischaemic stroke each year. Approximately 30,000 people live in the community with disabilities as a result of stroke.

Mechanical thrombectomy procedures have been provided in Ireland by specialist neuroendovascular radiologists in Beaumont Hospital and Cork University Hospital. Approximately 200 procedures were undertaken in 2016. However, in the absence of an organised national service, access to this procedure is not equitable, says HIQA.

The five-year budget impact of a national emergency mechanical thrombectomy service compared to no service is estimated in HIQA’s HTA at €7.2 million, comprising €3.3 million in the first year and annual running costs afterwards estimated at €0.8 to €1.2 million based on treating 268 patients each year. Moving from the current ad hoc service, through which 200 patients were treated last year using existing facilities, to a national service resourced with one new additional biplane angiographic suite would cost an additional €2.8 million over five years with €2 million of this incurred in the first year, according to HIQA.

Intravenous thrombolysis (anti-blood-clotting drugs injected into a vein to dissolve the clot) is part of standard medical care for the management of acute ischaemic stroke. In order for it to be effective and provide maximum benefit, it must be administered within 4.5 hours of the onset of stroke symptoms.

Endovascular therapy using mechanical thrombectomy devices aim to physically break up or retrieve clots and rapidly restore blood flow. This procedure is indicated as an addition to standard medical care in selected patients.